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Wednesday, October 30, 2013

The Nutrition Debate #156: The New ADA Nutrition Guidelines: Some Misgivings

My last
column, “Cowabunga,
the ADA makes the turn,” is my
overview of the groundbreaking move by the ADA to a patient-oriented
approach to healthy eating for type 2
diabetics. Their new Position Paper, “Nutrition
Therapy Recommendations for the Management of Adults with Diabetes”
is a truly refreshing breath of fresh air; it is completely devoid of evidence
of “industry support,” which plagues virtually every other dietary prescription
coming out of government, public health/medical organizations (e.g., AHA or
AMA) or public interest groups.

This new
Position Paper is in strong contrast with the “Dietary
Guidelines for Americans, 2010,” which
has hardly varied from its inception in 1980. The 1980 cover states in
boldface: EAT LESS FAT, SATURATED FAT, AND
CHOLESTEROL. Its predecessor document, the 1977 “Dietary
Goals for the United States,”
was prepared, not by scientists, but by the staff of the Senate Select
Committee headed by Senator George McGovern (Dem., S. Dakota) and aimed to
promote the corn and soy bean-based Agribusiness industry. If you want to get
your hackles up, read the “Illustrated
History of Heart Disease 1825-2015,”
a diet-heart “timeline” prepared by Diet Heart Publishing.

The
new
ADA Nutrition Guidelines are 22 pages long, including 14 pages of text and
tables and almost 250 references. While I obviously am very pleased that the
American Diabetes Association (ADA) has turned the corner on “nutritional
therapy,” I would still pick a quarrel here and there. Their glycemic, blood
pressure and lipid goals, for example, are unambitious
in the extreme: They adhere to the “general recommended goals of the ADA for
these markers.” Okay, they didn’t want to pick a quarrel there, obviously, plus
they allow that “they may need to be adjusted for the individual…” based on
various factors, from which I inferred (gasp!) less
stringent goals as “can be found in the ADA
Standards of Medical Care in Diabetes.”

And while this document was written by, for and from the perspective of the
Medical Nutrition Therapist (MNT), it acknowledges that “a large percentage of
people with diabetes do not receive any structured diabetes education and/or
nutrition therapy” and that “in addition to MNT provided by an RD, diabetes
self-management education and support are critical elements of care for all
people with diabetes and are necessary to improve outcomes in a disease that is
largely self-managed.” This point is very important
in two respects: Too few type 2 diabetics take responsibility for
self-education or self-care (readers of this blog excepted, of course). Most
type 2 diabetics just let their doctor (who is generally clueless in nutrition)
take care of their diabetes; he takes their blood, writes a script, tells them
to lose weight, and it’s “next patient”

The second
reason is that most RDs and CDEs haven’t got the
word yet; they still espouse the
one-size-fits-all dietary advice in the Dietary Guidelines for Americans
prescribed for the whole population, diabetics included – restricted-calorie,
low-fat, and thus high-carb – which is very bad for the general population
(raising their risk for CVD and diabetes) but disastrous
advice for type 2 diabetics. So, hopefully, these new recommendations
will have some impact on them, i.e., on the clinical practice of nutrition
therapy. I can hope so, anyway. You could help (they’re “busy”) by printing
this column – better yet, print the entire 22 page ADA document – and take it
with you to your next appointment with your MD, RD or CDE. It’s “continuing
education.”

Achieving
and maintaining body weight goals and delaying or preventing complications of
diabetes are other stated goals, and they say that “due to the progressive
nature of type 2 diabetes, nutrition and physical activity interventions alone
(i.e. without pharmacotherapy) are generally not adequately effective in
maintaining persistent glycemic control over time for many individuals.” Now
some of us (and I include myself among “us”), find that nutritional
therapy alone, totally without physical therapy or pharmacotherapy,
is sufficient in and of itself to keep type 2 diabetes in total remission!
Progressive disease, harrumph! I say
this as a T2 of 26 years.

Anyway,
achieving and maintaining body weight goals and delaying or preventing
complications of diabetes are very important goals and highly desirous. The
report states further, “More than three out of every four adults with diabetes
are at least overweight, and nearly half of individuals with diabetes are
obese.” And, “Among the studies reviewed, the most consistently reported
significant changes of reducing excess body weight on cardio vascular risk
factors were an increase in HDL cholesterol, a decrease in triglycerides, and a
decrease in blood pressure.” See #67, #68 and #70, here,
here,
and here
for my take on these topics.

“Weight loss
appears to be most beneficial for individuals with diabetes early in the
disease process.” (But your knees can benefit at any time.) If you are a newly
diagnosed type 2, this might be helpful, and the ADA Position Paper wisely
ducks the surgery issue. “Bariatric surgery is recognized as an option for
individuals with diabetes who meet the criteria for surgery and is not covered
in this review. For recommendations on bariatric surgery, see the ADA Standards
of Medical Care,” they say. I say, read The Nutrition Debate #145, “Gastric
Bypass vs. Medical Therapy for Metabolic Syndrome,”
carefully before you
contemplate bariatric surgery.

The ADA Position Paper does address the macronutrients individually, as
well as various micronutrients, vitamins and minerals. It also expresses a
“bias” (with reasons) for the Mediterranean Diet. I will delve into this and
other aspects of this important new blueprint into the frontier of “nutrition
therapy” in upcoming columns. Stay tuned. It should be interesting.

About Me

I was diagnosed a Type 2 diabetic in 1986. I started a Very Low Carb diet (Atkins Induction) in 2002 to lose weight. I didn’t realize at the time that it would put my diabetes in clinical remission, or that I would be able to give up almost all of my oral diabetes meds. I also didn’t understand that, as I lost weight and continued to eat Very Low Carb, my blood lipids would dramatically improve (doubling my HDL and cutting my triglycerides by 2/3rds) and that my blood pressure would drop from 130/90 to 110/70 on the same meds.
Over the years I changed from Atkins to the Bernstein Diet (designed for diabetics) and, altogether lost 170 pounds. I later regained some and then lost some. As long as I eat Very Low Carb, I am not hungry and I have lots of energy. And I no longer have any of the indications of Metabolic Syndrome.
My goal, as long as I have excess body fat, is to remain continuously in a ketogenic state, both for blood glucose regulation and continued weight loss. I expect that this regimen will continue to provide the benefits of reduced systemic inflammation, improved blood lipids and lower blood pressure as well.